1. MEDICAL FITNESS TO DRIVE Prepared by M. Bacchus and K. Locke MSH AIMGP Seminar Series 2003 - 2004

2. OBJECTIVES Understand the rationale and evidence for restricting driving privileges Understand physicians’ legal obligations in Ontario Understand the mechanism for driver reporting Understand the impact of specific medical conditions on the ability to drive

3. REFERENCE Canadian Medical Association, 2000. Determining Medical Fitness to Drive: A Guide For Physicians, 6th ed. (Sections are posted on Website) CMA members may also access at: http://www.cma.ca/cma/common/displayPage.do?pageId=/staticContent/ HTML/N0/l2/publications/catalog/driversguide/index.htm (sign into www.cma.ca first then paste the above)

4. Case 1 You are assessing a 43 year old female for follow-up of her epilepsy. Although compliant with her medications, she reports 3 seizures in the last 2 months. You a ) advise her not to drive b) advise her not to drive on highways or during rush hour c) advise her not to drive and report this to the Ministry of Transport d) take away her driver’s license

5. Learning Objectives understand principles behind determining patient’s ability to drive understand medical legal issues understand mechanism of reporting provide guidelines for driving for patients with seizure disorders

6. CMA Guidelines no hard and fast rules –individual assessments needed –“evidence” is mostly consensus opinion responsibility for issuing/taking away license rests with licensing authority, we only report where interest of individual driver and safety of public conflict, latter has priority

7. Medical Legal Aspects Liability in Ontario –mandatory reporting of unfit drivers –physicians protected from lawsuits if they report unfit drivers –physicians liable to negligence suits for failing to report unfit drivers, may have to pay damages Patients appeal directly to licensing authority –may have input from you as their physician Restricted license (eg daylight, not highways) not available in Ontario

8. Mechanism of Reporting A.See patient, examine for clinical condition B.If certain that patient should not drive, inform patient and make a report to the MOT C.If uncertain, obtain consultation, inform patient, and send report and consultation to MOT

9. Seizures - First Seizure no driving for at least 3 months until complete evaluation (EEG, CT) if no cause or no epileptiform activity –can drive class 5 (private vehicle) or 6 (motorcycle) if professional driver (class 1-4 license) –seizure free for 12 months

10. Seizure - After Epilepsy Dx if patient has diagnosis of epilepsy and compliant with anti-epileptic medications –can have class 5 or 6 license if seizure free on medications for 12 months –any class license if seizure free for 10 years on medications or 5 years off medications –Change meds: must wait 3 months –D/C meds: must wait 5 years

11. Back to Case 1 You are assessing a 43 year old female for follow-up of her epilepsy. Although compliant with her medications, she reports 3 seizures in the last 2 months. You a) advise her not to drive b) advise her not to drive on highways or during rush hour c) advise her not to drive and report this to the Ministry of Transport d) take away her driver’s license

12. Case 2 You are assessing a 45 year old TTC bus driver who is 3 weeks post anterior MI. He has a Gr III/IV systolic LV function and no reversible defects on Thallium GXT. He is medically managed and has NYHA II symptoms. He asks when he can return to driving his bus. You recommend a) 1 month from his MI b) 3 months from his MI c) 6 months from his MI d) never

13. Learning Objectives review guidelines for driving for patients with –coronary artery disease –arrhythmias –congestive heart failure

14. Coronary Artery Disease Stable AP - no restrictions/waiting period acute MI/UAP - after all initial management completed - private drivers - wait 1 month once stable - professional - wait 3 months once stable PTCA/Stents - private drivers - wait 48 hours - professional - wait 7 days and also reassess at 6 months with exercise stress test CABG - private drivers - wait 1 month - professional - wait 3 months

15. Cardiac Arrhythmias consider –frequency –risk of malignant ventricular arrhythmias –presence of other cardiac disorders VT/VF controlled on medications or ICD –private - wait 6 months –commercial- disqualified atrial arrhythmias and non-sustained VT –in general, can drive unless associated symptoms

16. Cardiac Arrhythmias AV block –disqualified for all classes if Mobitz type II, trifascicular block or acquired 3rd degree Pacemaker –can drive if asymptomatic 1 week after implantation for private, 1 month for professional driver

17. CHF, LV Dysfunction Private - can’t drive if NYHA IV symptoms Professional - can’t drive if –NYHA II symptoms or worse –EF < 35% –> 3 beats of VT on Holter, or > 10 PVCs/hour

18. Back to Case 2 You are assessing a 45 year old TTC bus driver who is 3 weeks post anterior MI. He has a Gr III/IV systolic LV function and no reversible defects on Thallium GXT. He is medically managed and has NYHA II symptoms. He asks when he can return to driving his bus. You recommend a) 1 month from his MI b) 3 months from his MI c) 6 months from his MI d) never (unless LV function, functional class improve on therapy)

19. Case 3 You are scheduled to see the following patients in your clinic today. Assuming no other medical problems, who would you consider safe to drive : a ) 62 year old with TIA 2 days ago b) 85 year old with pneumonia c) 50 year old truck driver with diabetes mellitus, starting on insulin d) 65 year old with syncope 1 week ago e) 55 year old taxi driver with dyspnea at rest from COPD

20. Learning Objectives review driving assessments for patients with –cerebrovascular disease –peripheral vascular disease –diabetes mellitus –syncope –lung disease review driving issues related to aging

21. Vascular Disease Single or Recurrent TIAs –cannot drive until assessed and investigated –can drive if no loss of function and cause addressed –if cause not clear: single - can drive; recurrent - can’t drive Completed Stroke –wait 1 month if minimal loss of functional ability and underlying cause addressed –if residual loss of function - road test (OT assessment) Aortic Aneurysm – if > 5 cm, treat surgically before allowing to drive

22. Age and Driving old age not a contraindication to driving driving may be critical to maintaining independence for isolated seniors increased prevalence of chronic diseases which may impair driving means increased frequency of medical exam for fitness to drive needed in older age (eg. yearly after age 80)

23. Diabetes Mellitus - Insulin Treated Private driver - OK if –no severe hypoglycemia within last 6 months Professional driver - OK if –no severe hypoglycemia within last 6 months –no instability of insulin regimen (e.g. starting insulin or changing dose, need 1 month wait) –no peripheral neuropathy (with loss of function), cardiac reasons, visual impairment –self monitors

24. Syncope Single episode and no cardiac/neuro cause found (if found - correct!) –private - wait 1 mo; professional - 3 months 2 or more in 12 months –private - wait 3 mo; professional - 12 months Recurrent events during waiting periods “reset the clock” Isolated clear vasovagal episode - no restrictions (may drive immediately)

25. Lung Disease COPD –private - OK unless on supplemental oxygen –professional - only if mild impairment (e.g. dyspnea uphill or walking quickly on level ground) portable oxygen –private - can’t drive unless pass road test with apparatus –professional - should not drive Obstructive sleep apnea (verified by sleep study) –OK if compliant with CPAP or successful surgery –History of somnolence (any cause): can’t drive

26. Case 3 You are scheduled to see the following patients in your clinic today. Assuming no other medical problems, who would you consider safe to drive a ) 62 year old with TIA 2 days ago b) 85 year old with pneumonia (if resolved, stable) c) 50 year old truck driver with diabetes mellitus, starting on insulin d) 65 year old with syncope 1 week ago e) 55 year old taxi driver with dyspnea at rest from COPD

27. Odds and Ends - Vision Visual acuity (both eyes open, examine together) –private - 20/50 –taxi - 20/40 –rest - 20/30 Colour vision –class 5 and taxis - no restrictions –others - discriminate red, green and yellow hemianopsias - no for all classes uncorrected diplopia within the central 40  of primary gaze - no for all classes

28. BOTTOM LINE If you aren’t sure, advise the patient not to drive and inform the ministry of transportation Interest of public has priority over that of individual driver (although take both into account)